Day: October 28, 2026

While affordability pressures are hitting Americans in many facets of their lives, from groceries to gas prices to housing costs, one important expense often gets less attention – childcare.

After a huge infusion of federal funds into childcare dried up at the end of the Biden administration, experts warned that this sharp cutoff, sometimes dubbed the “childcare cliff,” would force parents to either scale back work to handle the extra caretaking or pay steep costs out of pocket.

The potential effects of the federal cuts are hard to estimate, in part because states took different approaches in the aftermath. In some cases, they offset the sharp cuts in part by redirecting other funds to childcare.

But several states, including Vermont, New Mexico and Kentucky, have gone further and innovated on their own to shore up support for working parents and their young children. Meanwhile, New York City is expanding free toddler slots for lower-income families, following Mayor Zohran Mamdani’s announcement to build a universal early childcare system.

Taken together, these experiments point to bipartisan ways to support working parents, especially if the results of the November 2026 midterms signal a new willingness to tackle one of the biggest cost burdens for families.

As researchers of sociology and childcare policy with six children from 1 to 16 years old between us, we have also gained insights from our own data gathered over 75 interviews with parents in St. Louis, Missouri, over the past few years. We see them struggling with a fragmented childcare system that’s in need of a deep strategic investment. These families face limited choices and soaring costs for an essential good that allows a parent to go to work.

Out-of-pocket expenses for parents using center-based care in childcare centers and private preschool programs have more than doubled since 2019. In 2024, the national average price of childcare was US$13,128 annually, which rivals housing as the most expensive item in family budgets.

States go their own way

The disruption caused by the COVID-19 pandemic laid bare the critical role that reliable, high-quality childcare plays for working families. But we believe it also presented an opportunity for innovative investments in the nation’s fractured childcare landscape.

Pandemic relief legislation in 2021 directed nearly $40 billion to shore up the supply and quality of childcare. This funding increase, which was a fourfold jump over previous levels, supported childcare staff with higher wages and allowed for other investments to improve the quality of care.

The reach was vast, with stabilization funds flowing to 220,000 providers serving 9.6 million children. Many states also provided grants to create new slots and improve how providers got paid.

As those funds began drying up in September 2023, some states started to address these shortfalls on their own. In some cases, they took significant steps at a policy level to channel more support to working parents. We believe these investments could serve as examples for the rest of the country.

One is Vermont, which in 2023 became the first state to pass a law establishing a childcare entitlement. Following more than a decade of advocacy and bipartisan support, the law established a near-universal public childcare system, funded partially through a payroll tax of 0.44% split between employers and employees.

Through an expansion of subsidies along income tiers, the number of families covered rose by 55% from July 2022 to May 2025, while flexible grants increased the number of providers and focused on improving the quality of care. About 12,000 children are now covered under this program.

New Mexico went even further. In November 2025, the state became the first in the nation to offer universal childcare. Based on an older program that provided free childcare to low-income families, the initiative expanded support to all working parents regardless of income.

Before the expansion, 32,000 children were covered, a number the state aims to double by 2028. On average, the state estimates that the program will save families $12,000 a year.

Meanwhile, the Kentucky legislature in April 2026 passed a measure with strong bipartisan support to make major investments in the state’s childcare infrastructure. Key provisions include free childcare for the children of childcare center employees, increased state-subsidized reimbursement rates, and required training to support very young special needs children.

The Kentucky measure also loosened regulations that had made it tough for employers to share costs for care, such as renting facilities, while pitching a pilot program to open one-room “microcenters” in communities that lacked sufficient childcare options. In addition, Gov. Andy Beshear launched a complementary Pre-K for All pilot program in several counties.

Another example is New York City, where Mamdani has announced an expansion for toddlers as young as 2 years old in all five of the city’s boroughs, building on the city’s programs for free childcare for 3-K and pre-K. To date, this effort has increased some slots, although the rollout in September hit bumps.

The childcare crunch by the numbers

Given the skyrocketing costs, over 70% of families who sought care say it’s difficult to find childcare – and that doesn’t count the 11% who fail to find any at all, according to a 2023 government survey. That report found that families with Black or Hispanic children or infants, and those living in the South and West, are more likely to run into cost as a barrier.

On the supply side, three-quarters of providers say they have to turn many families away or put them on waiting lists. Center-based care for an infant costs more than in-state college tuition at a public university in 32 states, yet childcare workers, who are overwhelmingly women of color, earn the same as parking lot attendants and dog walkers. That makes them some of the lowest-paid workers in the entire economy.

Amid soaring costs and scarce supply, roughly half of all U.S. families live in so-called childcare deserts – areas where there are three children under 5 for every licensed-care slot. The answer for many families in these cases is to rely on ad hoc and irregular informal care. Some parents told us they’re turning to relatives and neighbors for help. Others resorted to using unlicensed, and potentially unsafe, childcare providers because they found no other viable options. And for some remote workers, the daunting solution is to care for their kids themselves while working.

The problem with such makeshift arrangements is that they tend, on average, to offer fewer of the learning opportunities linked to children’s long-term development and social mobility. And even these arrangements can be tough to afford: One single mother we interviewed told us she paid for a week’s childcare in kind with her own breast milk, which went to feed the care provider’s grandchildren. We also spoke to parents who reported choosing between childcare bills and heat, electricity or rent.

Another mom told us about a more unconventional solution. She and her husband work full time but can’t afford the childcare options in their community, so she decided to join a gym that provides free childcare while its members exercise. She brings her laptop and works, rather than working out, while her toddler plays.

These parents are scraping by in the absence of the affordable, subsidized childcare options commonplace in other countries. But this crunch is also a lose-lose proposition for the economy. The U.S. could lose as much as $290 billion per year by 2030 in forgone economic activity due to women not working or not working as much due to childcare pressures, according to the consultancy BCG.

A path forward

The Trump administration has laid out its own vision. Vice President JD Vance announced in September 2026 a preliminary proposal to repurpose existing funds for childcare subsidies as a cash transfer to married parents, provided that one spouse stays home. We believe, however, this approach fails to reflect the real needs of the millions of U.S. parents who can’t pay their bills if they only get one paycheck. In fact, under the subsidy program that Vance cited, only 16% of eligible children are reached today anyway.

We believe, based on our research, that any comprehensive overhaul has four important components.

First is a robust national policy for paid family leave, which would let families make the best care decisions for newborns, infants and parents themselves rather than sprinting back to work. Paid family leave would also ease demand for scarce infant care in the market.

Second is an expansion of early childhood care and education programs. By publicly subsidizing childcare, particularly for low-income families and special needs kids, policymakers can help close the affordability gap for high-quality care.

Third is a greater investment in childcare workers. Qualified caregivers are the cornerstone of high-quality childcare. If their wages and working conditions improve, it means fewer will have to take side hustles or quit for better jobs.

Finally, providers will need more incentives to open in underserved areas. Childcare is expensive to provide and runs on thin margins. In low-income and rural areas, many families can’t pay prices that cover the true cost of care, and subsidy payments are often set below that cost. So opening a center there doesn’t make much financial sense. Startup grants, higher subsidy rates and operating support help close that gap, which makes it possible to open and stay open where need is greatest.

Caitlyn Collins receives funding from Pivotal, Arnold Ventures, and the Weidenbaum Center on the Economy, Government, and Public Policy at Washington University in St. Louis. She is affiliated with the American Sociological Association, Work and Family Researchers Network, and Council on Contemporary Families.

Chloe Gibbs currently receives research funding from Arnold Ventures and Pivotal. She previously served with the President’s Council of Economic Advisers from 2022-23 with fellowship support from the Federation of American Scientists.

​Politics + Society – The Conversation

Inflation is causing real economic pain. Worries about healthcare costs have jumped sharply. And 7 in 10 Americans believe the country is in decline.

That is the landscape for the 2026 midterm election, according to a new survey from the American Communities Project at Michigan State University, which I direct.

The findings, which follow up previous data work the American Communities Project has done in 2023, 2024 and 2025, come from a survey of 2,155 American adults over two weeks in September 2026, conducted by the survey research firm SSRS, using an online panel and telephone, with a margin of error of +/- 2.4 percentage points.

The American Communities Project studies 15 types of communities. Taken as a whole, the national numbers reveal an electorate that is unsettled, gloomy and likely looking for change.

Inflation: Deepening concern

Cost of living is a unifying concern for all Americans. For the past four years, when given a list of 20 issues – including abortion, climate change, gun violence, drug addiction, education, healthcare, housing, immigration and taxes – respondents have consistently reported that inflation is the No. 1 issue in their community.

But the new data shows something more significant. Almost half of Americans, 47%, say they are experiencing real pain from rising prices – a sharp rise from previous years.

In 2023, 2025 and 2026, we asked respondents whether they were experiencing “serious financial problems” due to price increases. In July 2023, 27% answered yes. In 2025, 30% said yes. In 2026, 47% said yes. This significant swing underscores that many Americans across the country are really hurting in this economy.

For some groups, concern about costs reached well above 50%. For those ages 18-29 – members of Gen Z – 61% said they are dealing with serious financial problems because of price increases, the highest percentage among the four generational cohorts, including ages 30-49, 50-64 and 65+.

Cost of living was also a particular concern reported among people of color. Overall, 65% of Hispanics and 63% of Black Americans said they are experiencing serious financial problems because of price increases.

Healthcare: A rising issue

Healthcare emerged as a top issue in our new survey.

In 2025, 20% of respondents said it was a top concern in their community. This year, 30% cited healthcare as a top concern, a 10-point jump. That shift also made healthcare the No. 2 issue in this survey, after inflation.

For some demographic groups, concern about healthcare in their community reached above one-third of respondents. Among those whose income falls between US$75,000 and $99,999, 36% said healthcare is a top issue; among Black Americans, 35% said so.

This tracks with the policy changes and public health challenges since our 2025 survey. Many have lost health insurance, hospitals have closed, and disease outbreaks have affected communities.

It also may be tied to increasing costs overall. The pain people feel from inflation in healthcare can be especially acute because the dollar amounts can be large.

The United States in decline

The 2026 survey data also showed a 15-point jump in the percentage of Americans who agree with the statement: The United States is in decline. The number is at 70% this year, up from 55% in 2025.

In some ways that number makes sense. Consider the other numbers mentioned here – pain from inflation and concerns about healthcare – and the mood of Americans in general.

But there is another important point in the data. That number, 70%, is exactly what it was in 2023, the first year the American Communities Project did a survey. In 2025, the “decline” number dropped to 55%, and that change was largely driven by communities that voted for President Donald Trump in the 2024 presidential election.

It was a measure of hope for the future, and it showed in massive improvements in the general hopefulness in communities such as the evangelical hubs, concentrated heavily in the South, rural middle America and the middle suburbs.

The fact that the “decline” number is back to 70% suggests those same Trump-supporting communities have seen their hopes take a hit – and a deeper analysis of the data on the American Communities Project website shows just that.

At the very least, the data suggests a very disillusioned electorate.

Times and attitudes change

It’s important to keep the 2024 election in mind as the 2026 midterm elections near. It’s a sign of how opinions and attitudes can change – and quickly.

The data here represents this moment in time, and it will likely move after November, which is why we will field this same survey again after the new Congress is seated.

On Oct. 26 we released our more detailed community-level findings on the American Communities Project website. This data explores how opinions and attitudes differ depending on where and how people live.

Dante Chinni receives funding from the Robert Wood Johnson Foundation.

Ari Pinkus receives funding from the Robert Wood Johnson Foundation.

​Politics + Society – The Conversation

President Donald Trump’s approval ratings are cratering. Even his Make America Great Again, or MAGA, diehards have reservations.

This fact was evident to me when I attended MAGA rallies in three states on Oct. 24-25, 2026. One was a Turning Point USA get-out-the-vote event outside Harrisburg, Pennsylvania.

Along with a few dozen America First stalwarts wearing white “America the Beautiful” caps, I sat on a wooden table under a small picnic pavilion listening to speakers such as MAGA activist Scott Presler and Trump-endorsed U.S. Rep. Dan Meuser. Meuser reeled off MAGA talking points, including the supposed threat posed by transgender athletes and bathroom use, immigrant voter fraud and the “billionaire anarchist George Soros.”

Remarkably, the speakers barely mentioned Trump. The audience clapped politely, but the energy was tepid compared to the many MAGA rallies I attended in 2024, when the Pennsylvania landscape was dotted with Trump and MAGA signs. This time I saw none.

The numbers bear out what I observed.

A mid-October 2026 poll found that only a third of U.S. adults approve of the job Trump is doing; 71% feel the country is on the wrong track. The majority of Americans are pessimistic. A growing number worry about government corruption.

The reason?

There’s the war with Iran that has resulted in U.S. soldiers being killed and wounded. The conflict is costing billions of dollars and spiked the price of gas. But most of all, Trump has lost support on the economy amid growing inflation and an affordability crisis.

Remarkably, despite the headwinds, many of Trump’s MAGA loyalists still back him. This point was underscored by the Harrisburg event I attended as well as Trump’s midterm rallies, where attendees still enthusiastically chant “U.S.A.” and are decked out in red caps and MAGA merch.

Why?

I’m an anthropologist who has been studying Trump and his MAGA movement for years. I wrote a newly updated book, “It Can Happen Here,” on Trumpism and U.S. history. I have previously written about why people voted for Trump in 2024.

Based on my research, I see three key reasons some voters still back him. Meuser stressed all three at the Harrisburg rally as he warned of “lunatic” left socialism while extolling the Trump administration’s track record, including the immigration crackdown.

1. Socialist doomsday ‘fear porn’

While nervous about the war and inflation, many Trump supporters respond to fearmongering about “radical left” Democrats, some of whom, Trump contends, want to drive the country off a communist cliff.

If Trump has long harped on this putative radical left danger, his warnings have gained new traction with the visibility of progressive hard-liners like Michigan Senate candidate Abdul El-Sayed and the democratic socialist mayor of New York, Zohran Mamdani.

Beyond the threat of socialism, Trump claims that under Democrats the U.S. would fall back into a “dark age” of economic mayhem, curtailed rights and religious freedoms, rampant crime and imperiled national security. MAGA stalwarts echo his warning of “Doomsday” scenarios.

To underscore this point, Trump and his loyalists are connecting the massive and sometimes destructive protests in France to democratic socialists and the “radical left.”

For example, the White House posted a video on X featuring rioting and arson in France which warns, “Pay attention before it’s too late. This is the future Democrats want for America.” Other Trump supporters warn the unrest illustrates the civilizational threat of immigration and a looming “global Islamic takeover.”

MAGA pundits like Jesse Watters and Greg Gutfeld are encouraging this use of what they call “fear porn” to drive the 2026 midterm vote.

2. Border ‘invasion’ shut down

Trump won in 2024 largely due to two bread-and-butter election issues: the economy and immigration.

While those on the left focus on the abuses of Trump’s immigration agents, many Trump supporters I have spoken to credit him for clamping down on what they view as a Biden-era border “invasion.” It resulted, they claim, in the influx of millions of “illegal aliens,” some dangerous criminals, who have strained U.S. cities and taken jobs from citizens.

These Trump-supporting immigration restrictionists argue that reports of abuses by Immigration and Customs Enforcement are exaggerated and the need for mass deportations is urgent. If anything, some contend that Trump hasn’t done nearly enough in this regard.

MAGA loyalists give Trump higher marks on immigration than any other major issue, which is why the Trump administration foregrounds immigration as one of its top “promises kept.” This is why, in Harrisburg, attendees were told that when they went to knock on doors later in the day, they should mention Trump’s promises kept, including “No. 1, a closed border.” The tax cuts and drop in crime were Nos. 2 and 3.

3. ‘America is winning … bigly!’

Trump supporters feel the economic pinch. Some are unhappy about the war. But, they contend, Trump – who wrote the book “The Art of the Deal” – always has a long-term strategy and winning hand.

The proof?

Supporters point to Trump’s long and self-described successful business career and note what they perceive as the many successes of Trump’s first term.

And they contend that Trump has already delivered. As pro-Trump radio host Dan O’Donnell recently put it, under Trump “America is winning … bigly.”

Trump’s 2025 “One Big Beautiful Bill” cut taxes and government spending while delivering on campaign promises such as “no tax on tips” or overtime. Meanwhile, crime rates have plummeted, while the stock market has reached new highs.

A White House Jan. 20, 2026, press release – “365 WINS IN 365 DAYS; President Trump’s Return Marks New Era of Success, Prosperity” – lists a win for each day of the second term’s first year, some of which fact-checkers have shown are exaggerated. They range “from negative net migration for the first time in 50 years to the largest homicide drop on record, trillions in reshored investments, peace deals ending multiple wars, record energy production and massive bureaucracy cuts.”

MAGA stalwarts, like Trump, are sharing lists of such accomplishments, including Top 25 lists, to turn out the vote.

Trump’s bad polling numbers, some suggest, are the result of an anti-Trump “fake news” psyop. The reality, they say, is that Trump has launched, as he calls it, the “golden age of America.”

A Trump midterm ‘golden wall’?

Does this hardcore base of Trump voters create a “golden wall” that will head off the major midterm gains many expect Democrats to make? This possibility emerges especially in light of polling that has historically underestimated Trump voter strength.

But from my perspective, probably not.

There are splits in MAGA that I have observed firsthand at MAGA gatherings, such as the Conservative Political Action Conference and Turning Point USA’s AmericaFest. The war in Iran has been at the center of the dispute, with some – including former U.S. Rep. Marjorie Taylor Greene and commentators Tucker Carlson and Megyn Kelly – condemning what they call an “Israel First” faction for betraying MAGA’s “America First” principles.

In contrast, Democrats appear more energized.

Historically, the opposition party almost always makes gains during midterm elections – especially when there are economic troubles. And some wonder whether Trump supporters will turn out when he isn’t on the ballot.

Given the war and affordability crisis, it seems likely Trump’s “golden wall” of MAGA diehards, like those I saw at the Harrisburg rally, won’t be enough to stave off significant midterm losses, including control of the House of Representatives.

The question then will be what, if anything, Trump and his MAGA supporters will do about it.

Alex Hinton receives funding from the Rutgers-Newark Sheila Y. Oliver Center for Politics and Race in America

​Politics + Society – The Conversation

Three times a week, Amber Titus wakes up at 5 a.m. to get ready for the 45-minute drive to the methadone clinic.

Titus, 38, and her husband live with their two young children in Bisbee Junction, Arizona, a rural community near the U.S.-Mexico border. The couple started taking methadone, a medication that treats opioid addiction, in early 2025.

“It’s been a godsend,” she said.

But accessing methadone is not easy. The closest place they can receive treatment is a clinic in Sierra Vista, about 30 miles from their home.

The clinic opens on weekdays at 4:30 a.m. but closes before midday. Titus has to get her methadone dose and arrive at work in Bisbee before her shift starts at 9 a.m.

Arriving just 10 to 15 minutes late for an appointment can mean missing a dose because rules are so strict, she said, even when the clinic is still open.

That’s the routine when they have their own transportation. In August, their car was totaled in a crash. Until they got another one, Titus called Medicaid, her insurance provider, to schedule rides to the clinic.

“They said they’d be at my house at 6 o’clock in the morning,” Titus told The Conversation. The driver was late every day. “I missed my methadone dose for the whole week,” she said.

Nationwide, more than 120 people a day died from opioid overdoses in 2025, according to federal estimates. Methadone is one of the most effective medications for opioid use disorder, cutting the risk of fatal overdose by roughly half. Yet only 22% of people with the disorder ever receive it.

For more than five decades, only specialized, government-approved clinics, known as opioid treatment programs, have dispensed methadone, not regular doctors or pharmacies. Many clinics require patients to show up in person every single day, with average one-way drive times approaching 50 minutes in rural communities.

Today, private equity firms have acquired large shares of the market for methadone clinics, telling lawmakers their capital has expanded treatment and modernized care.

I am a healthcare economist at Brown University who studies how private equity is reshaping American medicine. My recent research on private equity’s growing footprint in addiction treatment, co-authored with researchers from the University of Pittsburgh and RAND, found that despite acquiring over one-third of methadone clinics in the U.S., private equity investments have not expanded methadone availability or the construction of new facilities.

This research has informed federal investigations into the role of private equity in expanding access to medications for addiction treatment. Currently, U.S. Sen. Maggie Hassan, D-N.H., has an investigation into three of the country’s largest methadone clinic operators, citing concerns that they oppose expanding treatment access for financial reasons rather than patient safety.

Why methadone fits the private equity model

Because methadone is so tightly regulated, opioid treatment programs are, in effect, a government-created monopoly.

In most of the country, if you want methadone, there’s a short list of clinics licensed to give it to you and no other way to get it. Moreover, people with opioid use disorder generally must travel to opioid treatment programs every day, where staff must observe them taking methadone, with strict limits on how much methadone patients can take home and when they can do so.

Take-home methadone varies based on the state, time in treatment and clinician discretion. Only 19% of people who received take-home methadone received three or more days’ supply.

That kind of guaranteed, captive demand is exactly the sort of investment that can be profitable for private equity investors. Whoever controls the clinics in a region controls access to the medication and can set the terms for patients in most need of medication.

Private equity firms have invested more than US$1 trillion in U.S. healthcare over the past two decades, touching everything from fertility clinics to hospice care. Many Americans have never heard the term private equity, but these firms now own more than 400 U.S. hospitals and oversee doctors in more than a quarter of the country’s emergency rooms.

In opioid treatment specifically, firms have used a platform and add-on strategy: buying one large clinic, then steadily acquiring smaller nearby ones, similar to a company quietly buying up every gas station in a county until, years later, one owner controls them all. Individually, each deal looks too small to matter. Collectively, a single firm can end up controlling an entire region’s methadone supply.

To be clear, private investment isn’t inherently harmful. Research shows that in markets where quality is easy to see, competition is robust and there’s no government subsidy – restaurants, for instance – private equity can have neutral or even positive effects. Healthcare has none of those features. Patients often can’t judge provider quality, they rarely pay for care directly, and government programs act as both payer and regulator.

Market share grew, methadone supply didn’t

My research has quantified what actually happened after private equity acquisitions of opioid treatment programs.

Previous research I have done, which my ongoing work builds upon, examined acquisitions from 2011 to 2019 and found that within two years of a private equity firm moving into a county, it typically controlled 67% of the local methadone treatment market – and in more than a quarter of counties, a single firm controlled all of it.

Despite acquiring that much market power, these acquisitions generally do not result in the construction of new methadone clinics or an increase in methadone treatment. Additionally, the data shows that methadone shipments, or what clinics have to dispense to patients, and opioid-related deaths were unchanged during the study period.

In plain terms: Private equity firms haven’t been building new capacity – they’ve been buying up the capacity that already existed.

As of October 2026, there are 1,572 methadone clinics registered with the Centers for Medicare & Medicaid Services. Nationally, 35% of opioid treatment providers are affiliated with private equity firms, and in 19 states and the District of Columbia more than half have private equity owners.

Montana has four clinics, all owned by Community Medical Services, more commonly known as CMS. The company was operating there before it was acquired by private equity. In North Dakota, CMS owns three of the state’s four methadone clinics. In Arizona, CMS owns the Sierra Vista clinic where Titus gets her methadone.

In 2018, a prospective investor advised shutting down CMS’ Montana and North Dakota clinics as unprofitable. Nick Stavros, CEO of CMS, opted to partner with a different private equity firm to keep the clinics open.

Before private equity investment, CMS had 14 clinics in four states. It now has 79 clinics in 14 states, according to Stavros. The total includes five clinics in prisons and three mobile units.

Unlike the typical private equity investment strategy of acquisitions, a majority of the company’s recent growth – 49 clinics – has come from new sites, he said.

No expansion has taken place in Montana. Building a new clinic costs about $2.5 million, more than many rural areas can support, Stavros said.

Proponents of private equity ownership argue it can help fill gaps left by inadequate public funding for addiction treatment. The strongest evidence in their favor: One study found clinics became significantly more likely to accept Medicare and Medicaid after acquisition, likely because large chains can afford administrative infrastructure that small, independent clinics cannot. That’s a real benefit worth acknowledging.

But look past insurance acceptance and ask whether more people are actually getting – and staying on – treatment, and the picture darkens.

For buprenorphine, a related medication that can be prescribed more broadly than methadone, one study found patient volume at private equity-acquired facilities rose about 22% after acquisition. Similar data for methadone was not available. But the same study found the share of patients who stayed continuously on buprenorphine for 180 days – the national quality benchmark – fell by nearly 8 percentage points. Early discontinuation is one of the strongest predictors of relapse and overdose.

A proposal to expand methadone access

These findings matter beyond academic journals, because they are at the heart of an active policy debate. Congress is weighing the Modernizing Opioid Treatment Access Act 2.0, which would let regular doctors prescribe methadone and let pharmacies dispense it, breaking the decades-old rule that methadone can be dispensed only at opioid treatment programs.

The Modernizing Opioid Treatment Access Act was introduced in 2023. After facing opposition, it did not reach a House or Senate vote before the end of the congressional term.

Lawmakers later reintroduced the bill with changes as Modernizing Opioid Treatment Access Act 2.0, which is currently in consideration by the Energy and Commerce and Judiciary committees. The committees have not yet scheduled the next step, a markup of the bill, and the current congressional term ends in January 2027.

In an email, U.S. Rep. Donald Norcross, D-N.J., one of the bill’s sponsors, recalled a snowstorm years earlier when he noticed a single track of footprints crossing an otherwise empty street to a methadone clinic.

“I realized that no matter what else is happening in the world,” Norcross said, “some of our neighbors’ lives literally revolve around getting to that building every single day.”

The bill has widespread support from patient advocacy organizations and medical societies. At the same time, a STAT investigation found that the main opposition to the legislation comes from the American Association for the Treatment of Opioid Dependence, AATOD, a major trade group representing methadone clinics. This coalition argues that expanded prescribing and pharmacy dispensing of methadone would increase diversion and overdose risk.

The evidence so far does not support that claim. Moreover, firms that control large shares of their local markets may have a financial incentive to keep new competitors, including doctors and pharmacies, out.

Mark Parrino, AATOD’s president, told The Conversation the trade group opposes the bill for two reasons. First, the bill would let the Health and Human Services secretary determine which additional practitioners are qualified to prescribe methadone for opioid use disorder. Second, it would allow methadone to be dispensed in dispersible tablet as well as liquid form.

Tablets “were definitely” involved in a rise in methadone-related deaths that began around 1999, Parrino said. The Centers for Disease Control and Prevention and a Food and Drug Administration advisory tied those deaths to methadone prescribed for pain, not addiction treatment.

Stavros, who is AATOD’s Arizona representative, said he did not see the bill as a threat to CMS’ business model, but he cited concerns that removing all regulation too quickly could allow a few bad providers to drive up methadone overdoses and increase stigma against the drug.

“We need to find ways to increase access,” he said. “If somebody would come up with … a slow, gradual transition that led to pharmacy prescribing,” Stavros said he would support it.

Dr. Melody Glenn, associate professor of addiction and emergency medicine at the University of Arizona, previously worked at a methadone clinic in Tucson and supports MOTAA 2.0, though she said the legislation should go further.

“It’s time to remove the regulatory barriers to these lifesaving medications,” Glenn told The Conversation in an email.

The bill would allow doctors specializing in addiction medicine, like her, to prescribe methadone. Glenn said it’s frustrating that such an effective treatment for opioid use disorder exists, yet many people who could benefit never receive it.

“They don’t have to die,” she said.

Bringing private equity deals into view

Two other policy responses are gaining traction.

The first is ownership transparency. Regulators, researchers and patients cannot scrutinize what they cannot see, yet private equity is exempt from the disclosure rules that apply to publicly traded companies.

Indiana, California and Maine have enacted or proposed reform to disclose private equity and management company ownership as a condition of being able to bill Medicare or Medicaid. Vermont passed similar legislation this year, on which I was invited to provide expert testimony.

The second is lowering the reporting threshold for acquiring a healthcare company to make them more visible to agencies enforcing U.S. antitrust laws, which are intended to promote competition and prevent monopolies.

The U.S. Department of Justice and the Federal Trade Commission consider ownership of 30% or more of a local market for a product or service a red flag for anticompetitive behavior. Yet, as my research shows, private equity chains typically control at least 67% of a local methadone market within two years of their first clinic purchase in a county.

The reason most never trigger the federal reporting requirement is because these acquisitions happen through a series of smaller, piecemeal deals rather than one large merger. The reporting requirement applies only to deals worth more than about $134 million. Some states have introduced proposals to lower thresholds to around $10 million specifically for healthcare deals, so the vast majority become visible to enforcement agencies before they close.

Structural barriers to getting treatment

The U.S. is experiencing an ongoing and severe opioid crisis. In 2023, approximately 80% of the more than 100,000 drug overdose deaths involved an opioid. In 2024, federal data shows the number of people who died from drug overdoses declined to nearly 80,000, and more than 54,000 of those deaths involved opioids.

We already have medications that work. The barriers preventing people from accessing them are not primarily clinical. They are structural – and, in this case, actively maintained by financial investors who profit from the status quo.

“Addiction isn’t a choice,” Titus told The Conversation.

She and her husband work for Cochise Harm Reduction, a grassroots nonprofit organization based in rural southeast Arizona that works to make life better for people who use drugs.

“It’s a learning curve and eventually … you get tired of it and you want help.”

Aleka Kroitzsh, researcher, and Kristi Tanner, senior accountability editor, contributed reporting.
The author of this article is supported in part by Arnold Ventures, which also provides funding for accountability reporting at The Conversation.

Yashaswini Singh receives research funding from the National Institutes of Health, Arnold Ventures, and the Commonwealth Fund, and serves on the advisory council of the Private Equity Stakeholder Project.

​Politics + Society – The Conversation